MCR20-039 11/20
Certified Historical Institutions | Certification Renewal
APPLICATION FOR CERTIFICATION Renewal
Application for: Tier 1 Tier 2
Date___________________________________________
Please refer to Guidelines for details of requirements and benets of each Tier.
Section I: ABOUT YOUR ORGANIZATION
Name of Organization _______________________________________________________________________________
Mailing Address ____________________________________________________________________________________
City _________________________________________________________________ ZIP Code ____________________
Physical Address ____________________________________________________________________________________
City _________________________________________________________________ ZIP Code ____________________
Phone _________________________________________ Email _____________________________________________
Primary Contact Name/Title __________________________________________________________________________
Contact Phone _______________________________________ Email ________________________________________
Alternate Contact Name/Title ________________________________________________________________________
Alt Contact Phone ______________________________ Email: _____________________________________________
Section II: Changes to your organization
Have there been any signicant changes to your organization in the past year? YES NO
If yes, please explain: _______________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
ATTACHMENTS REQUIRED: Roster of current board of directors/trustees (names only)
I hereby afrm that the above information is true and correct.
Name _____________________________________________________________________________________________
Title _______________________________________________________________________________________________
(President or Director required.)
Signature __________________________________________________________________________________________
Date _____________________________________________
Email completed form to: certied@azhs.gov Questions?Contact Nicola Brownlee at (520) 617-1141
Or mail to: Arizona Historical Society | 949 E. 2nd St. | Tucson, AZ 85719
NOTE: We prefer applications be submitted via email, however we will accept mailed applications for the
application period. Beyond 2021, we can no longer accept mailed applications. Do not send via certied mail, as
this will delay receipt.
